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Computers in the Exam Room

Does your doctor use a computer in the exam room? Some people think that computers are a great way to keep track of patient information. Others see some advantage, but problems in the implementation. There are also a few Luddites who oppose this change simply on principle. I’ve had good experiences, and bad experiences, and believe we have a long way to go before computers are as helpful as they could be.

There are two separate issues. The first one is quite significant: is there software that will do what doctors need it to do? The other issue is how computers affect the doctor-patient relationship – definitely another significant factor!

In every other field, the best way to buy software is to define what you need to do, then look for programs that will meet that need. To date, it appears that the accountants are shopping for software to meet their billing needs, without consulting physicians to determine what doctors want or need. Not being a doctor, I can’t really elaborate on that, but when doctors and nurses spend more time cursing the software than they do seeing patients and documenting the encounter, there’s obviously a problem.

As a patient, I’ve seen that computers in the exam room have an impact on the doctor-patient relationship. The doctor’s behavior is important. So is room setup. Both of these issues need to be considered.

One doctor I saw had exam rooms set up like this:

This is obviously a bad way to arrange a room. There’s a huge desk acting as a barricade between the doctor and the patient. When the patient is sitting in the chair, the doctor must look away from the patient in order to see the computer screen. No matter how caring a doctor might be, the patient isn’t going to perceive it when the doctor steps into the room, nods and waves at the patient, sits behind a desk to face the computer, and focuses on data entry. In this room configuration, the computer literally comes between the doctor and the patient.

In contrast, I’ve been in other exam rooms that handled the computer’s presence better:

Both of these room configurations allow the doctor to sit with the patient. No computer comes between them. My preference is for the room on the right, where the doctor is still 45° to the patient when looking straight at the computer screen.

These illustrations aren’t the only types of rooms I’ve seen. At Children’s Hospital, my daughter’s rheumatologist sits at the end of the exam table and talks with her. The computer is clear across the room, and data entry is done by a scribe; at the end of the appointment, the doctor clicks a few buttons. The computer seems to be a tool that helps provide prescriptions and information, not a deity to be worshipped by everyone in the building.

About eight years ago, I saw a doctor who carried a laptop from one room to the next. At my first appointment, he grinned and said that he found it easier to keep his notes on computer instead of paper. It didn’t affect the exam or our rapport. Everything seemed normal, except that he typed his notes instead of handwriting them. It worked well. That would be ideal (and should be easier today, with tablet computers).

My favorite way of handling computers, however, is the doctor who keeps the computer in his office and out of the exam room entirely. He obviously pulls my file up to refresh his mind before coming into the exam room. We talk and he does an exam, then he returns to his desk to type his notes while I dress, and there’s a prescription waiting at the front desk by the time I check out. It seems the most efficient, and the computer isn’t at all intrusive.

The worst computer setup I’ve ever experienced had the computer behind the doctor so that he had to turn his back to me. Or maybe that was a good thing – I was able to read over his shoulder. When he typed, “no pain on movement” I was able to ask, “Why would you say that?” He was astonished (1) that I was looking over his shoulder, (2) that I questioned him, and (3) that he got it wrong. He had asked if I could move my wrist, not if it hurt to move it. Huge difference – and we never would have known if I hadn’t looked at what he was typing. It would be incredibly easy for doctors to project their computer screen onto a wall so that the patient could see what’s being said. Patients might not feel quite so ignored while doctors are typing, and we’d know that the information going into our chart is accurate.

As more doctors switch to electronic medical records, patients will insist on the computer being a tool to help, not an interference. We will refuse to see people who make us feel like saying My Doctor is a Computer!

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Share your experience. Do you like computers in the exam room, or does their presence cause problems?

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3 thoughts on “Computers in the Exam Room”

Thoughtful post, Socks. My rheumatologist’s exam rooms are set up like the left hand design in your second illustration. He’s able to see me easily and vice versa.Most VA hospitals are completely computerized now; not only does he key new data into my medical records each time he sees me, he also has access to all test results, other medical info from other specialties, all of my prescriptions and can send new prescription orders or renewals directly to the pharmacy during my appointment.

Since the computer is such an integral part of the exam–and he has to type everything into it–the seating arrangement works. If I wish to see the screen, he can (and has, without protest) turn it slightly so I can read it. And he says out loud what he types, so I know exactly what’s being entered into my records. Since he’s a rather slow and careful typist, there’s a certain whimsy to the process. “Patient … … is … … exper … iencing … … increased … pain …”

Each doctor I see at the VA hospital has his or her own method for inputting data. My rheumatologist’s method, though, is the one I like best because I know exactly what’s going into my records. The good thing, too, is that each specialist, and my primary care doc, all have access to all my medical information. And should I be traveling and become ill my records are available at any VA medical clinic to any doctor treating me, in the country.

For all its ills –and there are some, particulary managing the huge influx of young, physically and mentally disabled veterans from Afghanistan and Iraq — the VA’s system is pretty darned good these days.

Interesting. I had not thought about it until now. My RA doc still uses pen and paper. I am on file #3. My primary doc uses a computer laptop that he cares from room to room. He sits so he is facing the patient. Prescriptions are sent electronically. What I don’t like is their new system of being able to email the doc through some portal that is cumbersome. I like that my docs can see each others labs and notes. Saves time having to call each other to find out info.

Our pediatrician has a little rolling table that he puts his laptop on when he comes into the room now. He can roll the screen over to me to show me stuff about the kidlets and roll it aside as he does the exam. It’s very nice.

My primary care doctor also carries in a laptop. He sits on a stool at an angle to the counter so he can see both the screen and me. (There’s a desk there that he doesn’t use because he can’t see the patient and the screen both at once) He’s never shown me the screen during the appointment (and I’ve never asked, actually), but the nurse always does so I can see my notes from the last appointment if I ask her to scroll down. He’s also the sort that talks as he types, so for the most part whatever he’s said is what he’s typed. Prescriptions are sent electronically. There’s only once been a problem with that and it was easily fixed by phone. (Upon thinking about it, my neurologist works the exact same way with everything.)

My rheumatologist’s office has a computer on a desk in each room. The nurse and doctor spend quite a bit of time logging in and out, which gets very old very quickly. I sit at a chair next to them and answer questions and see what they type in, so that’s all good. Prescriptions are done electronically and a printout is left for me at the front desk “just in case.” I’ve had to use the printout a few times.

My pcp and neurologist are within the same hospital system, so things transfer smoothly between them. My rhematologist and ob/gyn are associated with other hospitals, so things aren’t transferred between them the same way. However, my pcp writes letters to the other doctors (and sometimes to us letting us know he’s communicated with other doctors and their responses if things are “interesting”), so they’re generally kept up to date that way.